Medication nonadherence is a significant challenge for both the healthcare system and patients, and it’s estimated to cause an estimated $100-$290 billion in otherwise avoidable cost to the U.S. healthcare system each year, including poor health outcomes.
Studies have shown that 20 to 30 percent of medication prescriptions are never filled, and that approximately 50 percent of medications for chronic disease are not taken as prescribed, according to a review in Annals of Internal Medicine. For healthcare providers, this is a problem that is 100 percent preventable, but almost entirely dependent on engaging with patients to drive behavioral change.
Recent innovations with digital medicines offer the potential to tackle medication non-adherence in a novel way by providing digital pathways to track adherence and improve patient engagement. Desert Oasis Healthcare (DOHC), a medical group that serves the desert communities of Southern California, is collaborating with Proteus Digital Health, a Redwood City, California-based digital medicine company, to enroll up to 250 patients with cardiovascular and metabolic diseases, including hypertension and diabetes, in a digitally-driven medication adherence initiative. The goal of the program is to improve adherence and demonstrate improvements in clinical outcomes and reductions in hospital admissions for DOHC patients.
The U.S. Food and Drug Administration (FDA) granted the first approval of a digital medicine system in November 2017—Abilify MyCite, an aripiprazole tablet for the treatment of schizophrenia with sensor technology made by Proteus. Since then, Proteus has developed a pipeline of 31 digital medicines for mental health, cardiovascular metabolic conditions, infectious diseases and oncology. Proteus has conducted several clinical studies demonstrating the clinical and economic benefits of using digital medicines to improve outcomes in high-risk patients, including a successful randomized control trial in patients with uncontrolled hypertension and type 2 diabetes, according to the company.
The digital medicines are formulated so they communicate when they have been swallowed— a wearable patch detects medication ingestion and captures physiologic response and then sends real-time data on medication usage to a patient smart phone app and to a physician dashboard.
Since announcing the collaboration with Proteus this past August, Desert Oasis Healthcare has enrolled 50 patients identified as being non-adherent into the program and expects to have 250 enrolled in six months, according to Brian Hodgkins. Pharm.D., executive vice president of Desert Oasis Healthcare. So far, the program is seeing 88 percent medication adherence and patients are 90 percent adherent with wearing the patch. Once 250 patients have been enrolled in the initiative, which entails using the digital medicines for three months, DOHC clinical teams will then measure clinical outcomes based on control of blood pressure and hemoglobin A1c to determine if the program resulted in better medication adherence. Full results of the initial program will be available in about a year, Hodgkins says.
“This gives us a proven, FDA approved way to know when patients take their medications. We know for sure the medications that don’t work are the medications that are not taken.” Hodgkins says. “We’re doing this in the cardio-metabolic space because it’s something that we are very focused on and something that drives unnecessary healthcare costs and really has an impact on a patient’s sense of wellbeing. We’re trying to shift our focus on to the cure dollar, not the care dollar aspect of it.”
Another unique aspect of this multi-year collaboration between the medical group and Proteus is that it is based on a value-based contract whereby the digital company is at risk and will be paid when patients who are out of control on their hypertension or diabetes conditions achieve certain health goals. “The bottom line is, they have skin the game,” Hodgkins says of Proteus. “If we can get our patient population to be adherent, then, as a benefit to that adherence, we would expect to see decreased downstream costs. If we do see less hospitalizations, less ER visits or immediate care visits and that translates into cost savings, then we are going to share that cost savings with Proteus.”
DOHC, based in Palm Springs, serves over 70,000 patients in the greater Coachella Valley area and surrounding desert communities of Riverside and San Bernardino counties. Health care plans contract with DOHC who, in turn, contracts with a network of over 100 primary care providers, over 200 specialists, hospitals and diagnostic centers, and a continuum of health care systems. DOHC is a member of Heritage Provider Network (HPN), a large integrated healthcare delivery system primarily based in Southern California and with 30,000 physicians across several states. DOHC’s network includes home health, family hospice care and palliative care. The organization also participates in the Heritage California Accountable Care Organization (ACO), a Next Generation ACO as part of the Centers for Medicare & Medicaid Services (CMS) ACO program.
“Desert Oasis Healthcare has about 30,000 Medicare Advantage lives, about 30,000 commercial HMO lives and we’re also in the Medi-Cal space [Medi-Cal is California’s Medicaid program], and managed Medi-Cal space. Just in our local area, Coachella Valley, we have 75,000 patients that we are directly contracted to manage. And all of this is a risk-based model. The only fee-for-service space that we operate in is in the ACO, and that’s very small for us, we only have about 5,500 patients locally,” Hodgkins says.
In 2016, DOHC was recognized by the Integrated Healthcare Association, a California nonprofit group, as one of only six physician organizations to receive a 5-star rating for providing high quality health care to Medicare Advantage patients.
Hodgkins says DOHC leaders viewed the collaboration with Proteus as an innovative, “high-tech, high-touch” approach to addressing medication non-adherence among its patient population. “We’re a heavy population health-based healthcare model. We had been wanting to improve medication adherence, which is also part of CMS quality measures, and we thought this would help us get that last five yards,” he notes. “We have a lot of technology partners who have come to us with ideas about how to use technology to leverage our care teams and care strategies so that we can expand our reach and improve our outcomes. Our diabetic programs, our hepatitis C programs, our COPD (chronic obstructive pulmonary disease) programs, all of these rely on technology so that we can expand our scope and depth of practice. And this was just a natural fit for us.”
He adds, “We also have a very focused pharmacy team, it’s called Pharmacists in Population Health and Prescription Management, so we do everything we can to help our primary care doctors and provide some of the heavy lifting on care between those doctor visits.”
To roll out the initiative, DOHC leaders specifically focused on cardio-metabolic diseases, such as diabetics with hyperlipidemia and hypertension. “We focus on senior care; we pride ourselves on taking care of the elder population. Four out of ten seniors take more than five medications at a time. We realized if we could get our non-adherent, poorly controlled, hypertensive folks to goal, overall, it would be a benefit to the community, the wellness of the population and, overall, you spend less money.”
As part of this initiative, organization leaders leveraged data analytics to zero in on the at-risk population and identified 3,500 patients, out of 8,500 with cardio-metabolic diseases, who were non-adherent based on pharmacy claims data. “That means they are not filling their medications,” Hodgkins says. “We know that they have clinical outcomes measures in our electronic health record (EHR) that are not at goal. That could be diabetics with hemoglobin A1c greater than 9, or they have LDL cholesterol levels greater than 100.”
“If we can get these patients to goal, it improves the adherence and its improve downstream wellness, and then we can look at the rest of population to follow,” he says. “We know we’ll see decreased strokes, decreased MIs (myocardial infarctions), decreased hospital admissions for hypo- and hyperglycemic events; all the things that we’re trying to chase at any given time. For us, we look at hospitalizations as a failure of us to do our job to keep patients well enough where we could have addressed the situation in the outpatient arena.”
The aim of the initiative is to better engage patients through the digital platform and through coaching to encourage behavioral change, as engagement is often the missing piece in patient care.
“If you look at the chain of care, which is the patient being engaged with the provider and the whole care team, sometimes there are disconnects and patients don’t want to say, ‘I can’t afford the medication,’, or ‘I don’t like it.’ Or, they might say, ‘I don’t feel my blood pressure so why should I take it?’”
He continues, “This connects the dots for the whole care team and the patient. We’ve seen that it can be very powerful when patients see how well they are doing, they are encouraged.” Even in this early phase of the initiative, clinicians are finding that patients participating in the program benefit from the real-time data in the mobile app. "Patients can see their numbers improving and can make the association between adherence and clinical improvements," Hodgkins says.
And while it is a data-driven initiative, face-to-face engagement and education play a critical role, he notes. “We’re taking technology and adding it to our best practice and best care model to really move this very difficult, recalcitrant population into a space where they haven’t been before. So, engagement, coaching and education is critical for any positive outcome in healthcare, regardless of what tools or technology that you have at your disposal.”
